Recommendations from the ICM-VTE: Hip & Knee

Abstract

The ICM-VTE Hip & Knee Delegates* 1 -Is VTE after elective total joint arthroplasty a "never event"?Response/Recommendation: Venous thromboembolism (VTE) after elective total joint arthroplasty (TJA) continues to occur despite various strategies in prophylaxis and should not be considered a "never event."Strength of Recommendation: Moderate.Delegates vote: Agree 94.87% Disagree 5.13% Abstain 0.00% (Strong Consensus).Rationale: As part of an initiative to address quality of care and control healthcare costs, in 2002, the United States Centers for Medicare and Medicaid Services (CMS) defined "never events" as hospital-acquired conditions that were considered reasonably preventable 1 . In 2008, CMS added deep venous thrombosis (DVT) and pulmonary embolism (PE) following total knee arthroplasty (TKA) and total hip arthroplasty (THA) 2 .Historically, DVT and PE were important risks for patients undergoing TJA. In a study of 7,959 patients between 1962 and 1973, Charnley et al., reported a non-fatal PE rate of 7.89% and a 1.04% rate of fatal PE which constituted the highest single cause of death after a THA 3 . Coventry et al., identified a cohort of 2012 THA from 1969 to 1971 of which 58 did not receive chemoprophylaxis past post-operative day five and observed a DVT rate of 3.4%, a non-fatal PE rate of 5.2%, and a fatal PE rate of 3.4% 4,5 . In a series performed between 1990 and 1991, Warwick et al., identified 1,162 patients undergoing THA without routine chemoprophylaxis, with DVT confirmed by venography in 1.89% of patients and a PE rate of 1.20% with a subsequent mortality rate of 0.34% 6 .Early studies demonstrated a much higher incidence of VTE for TKA 7,8 . However, DVT in TKA patients occur distally in the calf which are less likely to progress into a PE which was observed at a rate of 1.3% 9 with fatalities of 0.19 to 0.4% 9,10 . Stulburg et al., examined a series of 638 patients from 1974 to 1979 among which 49 patients inadvertently did not receive prophylaxis; an impressive 83% of these patients developed a DVT 11 .In a prospective study with 34,397 consecutive and unselected THA or TKA procedures, 32 (0.09%) had a VTE after median two days despite ongoing thromboprophylaxis 12 . All surgery was done in a fast-track setup with accelerated mobilization and discharge. Another study has shown a 90-day incidence of 0.41% of VTE after unicompartmental knee arthroplasty 13 . All patients received thromboprophylaxis until discharge and were operated in a fast-track setup with a median length of stay of one day.With VTE as a common and potentially dangerous complication after TKA and THA, safe and effective strategies for prophylaxis were developed and studied. When warfarin dosage is titrated to an international normalized ratio (INR) of 1.5 to 2.0 and administered for approximately six weeks, DVT occurred at a rate of 0.2 to 1% with a non-fatal PE rate of 0.1 to 0.3% [14][15][16] . Warfarin was found to consistently decreased rates of VTE when utilized after THA or TKA, but may lead to a significant risk ...

Thromboprophylaxis with unilateral pneumatic device led to less edema and blood loss compared to enoxaparin after knee arthroplasty: randomized trial

“…One needs to consider, also, that those studies on DVT in the contralateral leg screened all patients [ 27 – 29 ], and not only the symptomatic ones — as recommended by ACCP [ 1 ] and AAOS [ 2 ]. The majority of patients with DVT are asymptomatic, though [ 11 , 30 ] and using anticoagulant medication for these patients would only increase the risk of bleeding, infection and operative wound complications [ 8 ].…”

“…We compared the unilateral IPCD with enoxaparin, and not with aspirin — a drug with increasing popularity in the last years. The most recent international consensus on VTE prophylaxis in knee surgery, published after the results analysis for this trial, recommends aspirin [ 30 ]. However, it is not yet a global trend, and especially it was not the preference of 87% of Brazilian orthopaedic surgeons, who preferred enoxaparin according to a national survey conducted in 2021 [ 31 ].…”

Modernizing Total Hip Arthroplasty Perioperative Pathways: The Implementation of ERAS-Outpatient Protocol

“…These are critical aspects of ERAS [ 8 , 42 , 43 ]. In a recent international consensus on venous thrombosis prevention, low-dose aspirin (80–100 mg) was recommended as the safest and most effective method of prophylaxis in patients undergoing hip or knee arthroplasty: “We recommend the use of low-dose acetylsalicylic acid (ASA) as the primary method of venous thromboembolism (VTE) prophylaxis in all patients undergoing THA, including moderate- to high-risk patients” [ 44 ].…”

International consensus on prevention of venous thromboembolism in patients after orthopedic interventions

“…У березні 2022 року опубліковано нові міжнародні рекомендації щодо профілактики венозної тромбоемболії в пацієнтів після великих ортопедичних утручань (Recommendations from the International Consensus Meeting on Venous Thromboembolism) [1][2][3][4][5][6][7][8][9][10]. Передумовою для створення цього консенсусу послужила недосконалість наявних даних і рекомендацій щодо профілактики тромбоемболії в періопераційному періоді.…”

“…Рекомендації містять розділ зі загальними підходами тромбопрофілактики після ортопедичних утручань [1] та спеціалізованими, зокрема: у разі хірургії верхньої кінцівки та зап'ястка [2], плеча або ліктя [3], стопи або гомілки [4], стегна або коліна [5], хребта [6], за умов онкології [7], у випадку операцій у дітей [8], після ушкоджень [9] і спортивних травм [10].…”